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Measles Among Adults Associated with Adoption of Children in China
--- California, Missouri, and Washington, July--August 2006

On August 15, 2006, the Missouri Department of Health and Senior Services (MoDHSS) was notified of a measles case in
a Missouri resident who had recently traveled to China. The patient had traveled with a group of 11 families seeking to
adopt children from three orphanages in Guangdong Province. Members of the group, which was sponsored by a
Missouri-based adoption agency, traveled separately but stayed at the same hotel in Guangdong Province during July 13--27. This
report describes the multistate investigation that followed, which identified two additional measles cases. None of the three
patients recalled contact during travel with anyone who appeared ill. All three patients recovered fully, and no secondary cases
were identified among family members, other travelers, patients, or medical staff who might have been exposed. Because of
delays in diagnoses (the earliest case was identified 2 weeks after rash onset), no control measures (e.g., vaccination of contacts
or administration of immunoglobulin) were indicated. Communicable diseases that are no longer endemic in the United
States continue to occur among travelers, often resulting in delayed recognition and delayed notification of public health
authorities. Because of the risk for spread in the community of imported communicable diseases such as measles
(1), thorough investigation is needed to determine possible sources of infection and the extent of disease spread in the community.

Case 1. On July 13, a woman from Missouri aged 36 years traveled with her husband to Guangdong Province.
She returned to the United States on July 28 with her husband and their adopted child. On July 30, she had onset of fever.
The next day, a rash appeared on her face and trunk. On
August 2, she sought medical care and was tested for tickborne
illnesses endemic in rural Missouri (e.g., Rocky Mountain spotted fever and ehrlichiosis). On August 9, a measles
immunoglobulin M (IgM) antibody test was obtained, which was reported positive on August 14. The patient had received 2 documented doses
of measles-containing vaccine (MCV) in her lifetime (1 dose at age 11 months and another at age 10 years). She and
her husband had stayed at the same hotel as 10 other U.S. families while awaiting finalization of their adoptions. On August
15, the CDC Division of Global Migration and Quarantine (DGMQ) was asked to assist in contacting potentially
exposed passengers on both a trans-Pacific flight and a domestic flight, on which the patient had flown during her return trip
from China. On August 18, a list of trip participants was
obtained from the adoption agency. MoDHSS contacted each family
by telephone and identified two additional cases of rash illness (cases 2 and 3) in persons from the adoption group.

DGMQ collaborated with MoDHSS to obtain the passenger manifests (i.e., lists of passengers and their
seating assignments) and available passenger-locator information (i.e., personal contact information for passengers) for
potentially
exposed passengers on the international and domestic U.S. flights on which the patient from Missouri had flown.
Six passengers seated near the patient on the international flight were identified as potentially exposed; all six were contacted,
and none reported symptoms consistent with measles during one incubation period (7--21 days) after the flight. The
passenger manifest and passenger-locator information
for all passengers on the domestic U.S. flight were obtained because no
seating was assigned for the flight.

Contact information was available for 101 of 118 passengers. DGMQ provided that information to the state
health departments in states where passengers resided. The number of passengers who were contacted by the state health
departments is unknown. No measles cases associated with this flight were reported to CDC.

Case 2. On August 2, a woman from California aged 39 years, who had been part of the same adoption trip, had onset of
a maculopapular rash on her face, chest, and back. She had returned from China on July 28 and thus was not
considered infectious* during her return travel to the United States. She had no fever, coryza, cough, or conjunctivitis. MoDHSS
learned of this patient's symptoms while interviewing the
patient from Missouri and notified the California Department of Health
on August 16. A measles IgM antibody titer was obtained and was positive. The patient reported receiving at least 2 doses
of MCV in her lifetime, for which no documentation was available.

Case 3. On July 29, a woman from Washington aged 38 years was evaluated in the emergency department of a
military hospital for fever
(102.9°F [39.4°C]) and a maculopapular rash on her chest and face. She described headache, facial
swelling, cough, nasal congestion, nausea, and diarrhea that began July 27 while en route from China to Seattle. Her symptoms
initially were attributed to amoxicillin she was taking for sinusitis diagnosed before her travel, and the drug was discontinued. On
July 31, approximately 48 hours after discontinuing the antibiotic, she returned to the hospital with continued fever and rash
that had progressed to her trunk and arms. She was hospitalized for 4 days to evaluate her
symptoms and elevated levels of hepatic transaminases. Viral hepatitis studies were negative. The patient improved and was discharged home. On August
21, MoDHSS notified the Washington State Department of Health (WSDH) that the woman had traveled with the
adoption group. Serum obtained on August 22 by the local health department was reactive for measles IgM antibody. The patient
had received 1 documented MCV dose at age 1 year.

WSDH and CDC were unable to identify contacts of the patient from Washington on the international flight because
a manifest from the carrier could not be obtained. For the interstate flight, the delay in receiving notification of the
patient's illness meant that the airline was unable to provide the manifest for the indicated flight in a timely manner. Therefore,
a manifest was not requested by WSDH.

Editorial Note:

During 2001--2005, import-associated measles cases (i.e., imported, import-linked, or imported
virus cases) accounted for the majority of cases reported in the United States
(1,3,4). Imported measles cases among adoptees from
China have been reported previously (4,5). This report documents imported measles cases during July--August 2006 among
adopting parents from the United States who were exposed to measles while visiting China.

China is the leading country of origin for foreign-born children adopted in the United States
(6). During 1998--2005, annual U.S. adoptions of children from China increased by 88%, from 4,206 to 7,906
(6). A national measles outbreak in China increased reported measles cases there from 70,549 in 2004 to 124,219 in 2005
(7). In Guangdong Province, 11,146 measles cases were reported during January--June 2006, a 30% increase compared with the same period in 2005
(8). This situation in China presented an increased risk for measles exposure to travelers and potential importation into the
United States. China has set a measles-elimination goal for 2012, and the country is conducting activities to achieve this goal
(e.g., conducting an international field review [November 2006] and convening the first National Technical Advisory meeting
on measles elimination [December 2006]).

According to the Advisory Committee on Immunization Practices (ACIP), persons born during 1957 or later without
1) adequate documentation of immunity by previous vaccination with 2 doses of MCV, 2) laboratory evidence of
immunity, or 3) physician-diagnosed measles should be vaccinated with the measles, mumps, and rubella (MMR) vaccine before
travel abroad (9). The U.S. Department of State requires that internationally adopted children aged >10 years receive the
following
vaccines before entry into the United States: measles, mumps, and rubella; polio; tetanus and diphtheria toxoids;
pertussis; Haemophilus influenzae type B; hepatitis B; varicella; and pneumococcal. For those aged
<10 years, the adopting parents must sign an affidavit promising to provide these vaccinations within 30 days of entry to the United States. The education that
most adoptive parents receive regarding their own medical preparations before travel can vary substantially. In this
instance, the adoption agency provided the ACIP recommendations to the clients and repeatedly advised their clients about the
importance of being properly vaccinated; however, no standard mechanisms were in place to ensure that these recommendations
were followed before travel abroad. In the United States and internationally, several organizations (e.g., the American Academy
of Pediatrics Section on Adoption and Foster Care and the Joint Council for International Children's Services) are working
to improve immunization and education standards regarding international adoptions. Health-care providers should continue
to promote appropriate pretravel vaccination for their patients.

Investigation of all three cases was substantially delayed
because of delays in diagnosis and delays in notifying
jurisdictions where exposed travelers resided. Because measles is rare in the United States (as a result of high immunization levels), it
is often unrecognized by clinicians who might not consider measles in a differential diagnosis. Health-care providers
should routinely gather information regarding the patient's travel history and maintain a high level of suspicion for measles
in patients with rash, fever, and recent travel to areas of known measles endemicity. Although a single dose of measles
vaccine administered in the second year of life induces immunity in 95% of vaccinees
(10), cases can occur even among vaccinated persons. More common than vaccine failure is incomplete documentation or inaccurate recall of vaccination status. In
the cases described in this report, the patient from
Missouri had 2 MCV doses documented, the patient from Washington had
1 MCV dose documented, and the patient from California had no MCV doses documented.

DGMQ is authorized§ to conduct investigations involving international flights arriving in the United States and
can assist state health departments with investigations involving interstate flights. In the case of interstate flights, DGMQ
may request passenger manifests and passenger-locator information to assist the state in which the plane lands. Once notified of
an exposure, DGMQ contacts the airline to obtain the passenger manifest and
passenger-locating information of contacts. A software application developed by DGMQ, eManifest, is used to securely import, sort, and assign
passenger-locator information to jurisdictions. These data are transmitted
securely to state and territorial health agencies via the
Epidemic Information Exchange (Epi-X) forum. Staff from the 18 CDC quarantine stations follow up with public health agencies
to ensure the information has been received. DGMQ continues to work with airlines to develop mechanisms for the
timely provision of passenger-locator information to CDC and with federal and state partners to improve the process of
distributing this information.

Acknowledgment

The findings in this report are based, in part, on contributions by C Queen, Harrison County Health Dept, Missouri; and S Hadler,
Z Shuyan, and Y Takashima, WHO Representative Office, China.

* The infectious period for measles generally is considered to be from 4 days before the onset of rash to 4 days after the onset of rash. The California
patient completed travel 5 days before the onset of rash.

 Imported measles includes cases in which exposure and infection occurred outside the United States; import-linked measles includes indigenously acquired
measles that is epidemiologically linked to an imported case; imported virus measles includes indigenous cases that are caused by a known imported measles genotype
but do not have an epidemiologic link to an imported case
(1,2).

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